Sabrina Wang: You’re on campus to speak about drug pricing and access to medicines, a policy domain that often involves the pharmaceutical industry. In light of the growing prominence of public private partnerships in policymaking, what do you believe is the ideal role of private industry in global health governance

Suerie Moon: Ideally, I would want a socially responsible pharmaceutical industry to invent, and develop safe, efficacious medicines that meet unmet health needs. And to ensure that the products that they develop are affordable to all populations, from the poorest countries in the world to the wealthiest. I think it’s possible for the industry to do that, but I don’t think that is what the industry is doing right now.

SW: Do you believe that there are any overarching ways we can ensure that companies occupy this ideal role, or at least move closer towards it?

SM: To get the industry to function and behave in a way that meets public health needs of a global society, I think, at the end of the day, is in the hands of governments. I don’t think we’re going to get the kinds of changes that we need only through persuasion, nor through corporate social responsibility initiatives. Especially today with high drug prices in the core markets of the US, Europe, and Japan, where these corporations make the lion’s share of their revenue. If we want to change their pricing practices, it’s not enough to change norms about responsibility. It’s certainly not enough to tweet. It’s not enough to scold publicly. You have to change laws and policies and incentives, and that of course is in the hands of governments, and [also] where I think we have some big problems. Because if governments are unduly influenced by the industry—through a form of political corruption—then the chances of us getting the laws and policies that we need diminish pretty quickly.

SW: Would you say that governments are equally central for the international policymaking process as well? With the profusion in the number of NGOs, power is no longer held solely by traditional stakeholders in the international realm, and international law is far less formal than national law. Due to these features, some argue that WHO [World Health Organization] and other such intergovernmental bodies are no longer as central to the global policymaking apparatus. How would you respond to those arguments?

SM: WHO, as an organization of governments, plays a really important role in helping governments address and craft legislation that would influence the behavior of the industry. WHO certainly has no power to pass any laws itself. So in terms of where the power still sits—I think it’s very much with national governments, especially for high-income industrialized countries, which are still the bulk of the global pharmaceutical market. Now that said, middle income countries are where most of the revenue growth is coming from for global pharmaceutical companies. So the policies that they adopt are increasingly relevant for the bottom line for drug companies. Low income countries remain a very small part of the global market, and the de facto impact on industry of policies in low income countries is likely to be pretty small—but this also presents an opportunity, as low income countries have more political space to take a flexible approach, for example, to patent laws in order to lower medicines prices.

So where does this mean WHO’s influence is particularly important? I think it’s in the middle income countries today. WHO has an important role to play in convening [these countries], bringing governments together to help [them] exchange experiences and strategies and engage in collective action—for example pooled procurement or joint price negotiations. There’s a lot of untapped potential for governments to collaborate better with each other, and WHO is often the central force [in calling] together governments who can usefully help each other. And I think that’s really critical. Because unless governments already have regional bodies through which they collaborate—like the EU [European Union] or ASEAN [Association of Southeast Asian Nations]—it’s often through WHO that those officials get in touch with each other.

WHO can [also] collect data and issue reports that inform the thinking of officials. I think that WHO’s reputation as a source of authoritative advice and expertise remains very strong in developing countries; the information coming from WHO carries a lot of weight with governments and therefore can shape the policies that they ultimately adopt. So, I actually think that WHO’s role in global health is more central than ever. But because it is not always appropriately equipped to play that role, another important question to ask is whether it’s becoming weaker because of resource constraints and/or the political maneuvers of its member states. But the importance and responsibilities of the institution have never been higher.

SW: It’s interesting that you paint the WHO as this advisory body—an institution involved more in knowledge generation than policy-making. Around ten years ago, WHO adopted the FCTC [Framework Convention on Tobacco Control], the first global health treaty established under their authority. There are some scholars in the global health policy field who believe that the framework convention approach should be applied to global health as a whole. Considering you don’t view the WHO to be as much of a policymaking body, what role do you think treaties play in global health governance?

SM: I think that in theory, and in a better world, treaties and formal international law would be a more important and effective tool for international governance. And I think the FCTC is an important and at least partially effective tool to reduce the health harms of tobacco. To me, the big question in 2019 is—are governments willing to come together and submit themselves to binding obligations in issue area X, whatever that X [may] be? My read on the current state of the globe is no: that the world is increasingly divided, that governments are increasingly unwilling to submit to and create formal international law. And at the end of the day, it’s governments and states that create and withdraw from treaties. So I am less optimistic that a progressive treaty would be possible politically, or that governments would be willing to negotiate a treaty that would be worth the time and effort in the first place. That doesn’t mean that if such a treaty were to exist, it couldn’t be effective. But if governments are not willing to actually craft something that would have an impact, then there’s no point.

SW: WHO studies of the effectiveness of the FCTC demonstrate mixed progress across policy domains and countries. These findings seemingly line up with your belief that the power is really held by the states—it’s possible that the treaty is superfluous, and states are doing what they would’ve done anyway. It’s hard to determine any causality there.

SM: [As] a generally big supporter of international law, the opinion that I give on the utility of treaties for all these global health problems comes from more of a political read of the situation today. I do think the FCTC has been an important mechanism for tobacco control in ways that are not always possible or easy to capture empirically. It’s hard to prove the impact of international law and [determine] what states would have done regardless, [but] I think that the widely held societal norm against tobacco use, which is very consolidated today, has been reinforced with the existence of the FCTC, particularly in developing countries that do not have as long a history of tobacco control measures. And that it’s a way to diffuse norms, [as well as] to build communities of advocates and practitioners through the regular gatherings at the conference of the parties. These are very important social impacts—changing the way people think is as important as the legislation that gets signed into formal law.

In this day and age, informal arrangements—[as in those] that do not necessarily require interstate negotiation of a treaty—are more likely to have a practical impact in the medium term. If we think about a number of significant developments in global health over the last 20 years, very few of them involved formal international law: the FCTC and International Health Regulations (2005) are the only big ones. You didn’t need a treaty to create the Global Fund, you didn’t need one to create Gavi [the Vaccine Alliance] or Unitaid. Each of these initiatives [formed from] a relatively small group of actors [agreeing to] do something about a problem and to cooperate transnationally and pool resources—whether it’s money or expertise or political power—to do so. And I think that’s where we’ve seen important progress being made.

SW: It seems by the nature of informal norms, social movements and advocacy organizations have a larger role to play, in convincing transnational actors to take on certain projects. But in the face of these large-scale inequities, it can seem really daunting to be an individual who cares about global health. Do you believe that the individual has a role in creating a more equitable global health world, and what do you think it is?

SM: Yes. I do think individuals and agency and leadership still matter quite a lot. And sometimes it’s individuals who are already powerful – for example, many people credit Dame Sally Davies , the chief medical officer of the UK, for making antimicrobial resistance into a high priority issue on the global agenda. And it’s partially that she has the might of the [UK] government behind her. But a lot of it is her determination; she is really passionate about this issue and has infected other people with her passion. Somebody who might be less obvious: Zackie Achmat, from the Treatment Action Campaign in South Africa, was very much at the forefront of advocating for access to generic treatment for HIV/AIDS across the developing world. His NGO was small and they didn’t have a huge budget—but wow, the impact that he had. He wasn’t an isolated individual, and most individuals aren’t isolated, but I think he is really an example of somebody who—through force of will and conviction and through relationships and strategy—had a big impact on the global debate. Researchers, too—in research you oftentimes have small teams of people who aren’t necessarily the Bill Gates of the world really having an impact on how we respond to public health challenges.

SW: So the lesson is to keep on keeping on.

SM: Right.

SW: Finally, many of our students are interested in global health policy careers—myself included. Do you have any career wisdom to impart?

SM: I think it’s a terrific field to go into, and there are a lot of different ways in which you can contribute. Many people still think immediately about medicine or public health, and those are of course very important fields of study. [But as] many health challenges have transnational determinants, we also need people who understand how the international system works—and doesn’t work. We need social scientists, activists, researchers: the set of skills that is needed to make a difference in the field of global health is very broad. So the first thing I would say, especially for undergraduates, is to think about your own interests and passions, and what you think you can contribute—what you’re good at and what gets you excited and out of bed in the morning. Think about that before thinking about which specific graduate school or path or organization to work in.

The second thing is, many students won’t have the opportunity to live and work day-to-day in their [setting of interest]. For example if you’re interested in working on health in a resource-limited low-income country, living in such a country for at least a year, preferably two, is one of the most valuable things [students can do.] There’s no replacement for living and working and learning about what makes it so difficult to change things. I think that’s often hard to appreciate from afar, and it’s always much more complicated than [what we may think].

And to do that before graduate school makes sense. Many students are often in a rush to finish, but I think that—having taught MPH and PhD students—it’s much harder to get the most out of an educational experience without having done some work in a resource poor setting, whether in the US or internationally. If working in resource poor settings and among marginalized communities is what motivates you, really trying to understand better these people, communities, histories, and politics, makes graduate school a more useful and enriching experience.